Basic Information
| Provider Information | |||||||||
| NPI: | 1518280395 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SAINT LUKE'S PHYSICIAN GROUP I, LLC | ||||||||
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| OtherOrganizationName: | SLCC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 901 E 104TH ST | ||||||||
| Address2: | MAILSTOP 400 | ||||||||
| City: | KANSAS CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 641314517 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8165028782 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4330 WORNALL RD | ||||||||
| Address2: | SUITE 2000 | ||||||||
| City: | KANSAS CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 641115939 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8169311883 | ||||||||
| FaxNumber: | 8167563645 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/08/2010 | ||||||||
| LastUpdateDate: | 04/12/2017 | ||||||||
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| AuthorizedOfficialLastName: | STASI | ||||||||
| AuthorizedOfficialFirstName: | JOSEPH | ||||||||
| AuthorizedOfficialMiddleName: | P | ||||||||
| AuthorizedOfficialTitleorPosition: | CAO | ||||||||
| AuthorizedOfficialTelephone: | 8165999587 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0001X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Clinical Cardiac Electrophysiology | 207RI0011X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology | 363LA2200X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 363LF0000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 207RC0000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | DQ3022 | 01 | KS | RAILROAD MEDICARE | OTHER | 200675870B | 05 | KS | MEDICAID | 1518280395 | 05 | MO | MEDICAID | DQ3775 | 01 | MO | RAILROAD MEDICARE | OTHER | 200675870A | 05 | KS | MEDICAID |